Cost-Effectiveness of Robot-Assisted Radical Cystectomy vs Open Radical Cystectomy for Patients With Bladder Cancer
Authors: Simon Dixon, Harry Hill, Laura Flight, Pramit Khetrapal, Gareth Ambler, Norman R. Williams, Chris Brew-Graves, John D. Kelly, James W. F. Catto, E Ruth Groves, Louise Goodwin, Jayne Willson, Phillip Ravencroft, Stephen Kennish, Derek J Rosario, Carol Torrington, Rajesh Nair, Ramesh Thurairaja, Sue Amery, Kathryn Chatterton, Samantha Broadhead, David Hendry, Abdullah Zreik, Sunjay Jain, Steve Prescott, Hannah Roberts, Angela Morgan, Chris Main, Elspeth Bedford, Lorraine Wiseman, Bernice Mpofu, Claire Daisey, Michelle Donachie, Jon Aning, Lyndsey Johnson, Carol Brain, Constance Shiridzinomwa, Martin Ebon, Alexander Hampson, Roisin Schimmel, Scott Horsley, Sayyida Nembhard, Clare Collins, Jemma Gilmore, Faith Wilson, Louise Peacock, Sheena Lim, Rhosyll Gabriel, Rachael Sarpong, Melanie Tan
Journal: JAMA Network Open (2023)

Importance The value to payers of robot-assisted radical cystectomy with intracorporeal urinary diversion (iRARC) when compared with open radical cystectomy (ORC) for patients with bladder cancer is unclear. Objectives To compare the cost-effectiveness of iRARC with that of ORC. Design, Setting, and Participants This economic evaluation used individual patient data from a randomized clinical trial at 9 surgical centers in the United Kingdom. Patients with nonmetastatic bladder cancer were recruited from March 20, 2017, to January 29, 2020. The analysis used a health service perspective and a 90-day time horizon, with supplementary analyses exploring patient benefits up to 1 year. Deterministic and probabilistic sensitivity analyses were undertaken. Data were analyzed from January 13, 2022, to March 10, 2023. Interventions Patients were randomized to receive either iRARC (n = 169) or ORC (n = 169). Main Outcomes and Measures Costs of surgery were calculated using surgery timings and equipment costs, with other hospital data based on counts of activity. Quality-adjusted life-years were calculated from European Quality of Life 5-Dimension 5-Level instrument responses. Prespecified subgroup analyses were undertaken based on patient characteristics and type of diversion. Results A total of 305 patients with available outcome data were included in the analysis, with a mean (SD) age of 68.3 (8.1) years, and of whom 241 (79.0%) were men. Robot-assisted radical cystectomy was associated with statistically significant reductions in admissions to intensive therapy (6.35% [95% CI, 0.42%-12.28%]), and readmissions to hospital (14.56% [95% CI, 5.00%-24.11%]), but increases in theater time (31.35 [95% CI, 13.67-49.02] minutes). The additional cost of iRARC per patient was £1124 (95% CI, −£576 to £2824 [US $1622 (95% CI, −$831 to $4075)]) with an associated gain in quality-adjusted life-years of 0.01124 (95% CI, 0.00391-0.01857). The incremental cost-effectiveness ratio was £100 008 (US $144 312) per quality-adjusted life-year gained. Robot-assisted radical cystectomy had a much higher probability of being cost-effective for subgroups defined by age, tumor stage, and performance status. Conclusions and Relevance In this economic evaluation of surgery for patients with bladder cancer, iRARC reduced short-term morbidity and some associated costs. While the resulting cost-effectiveness ratio was in excess of thresholds used by many publicly funded health systems, patient subgroups were identified for which iRARC had a high probability of being cost-effective. Trial Registration ClinicalTrials.gov Identifier: NCT03049410